PARTICIPATORY HIV/AIDS EDUCATION
IN BANGLADESH: A CASE STUDY
Ane Aamodt Aadland
Molde University College, Norway
ABSTRACT This paper discusses research in which I examine the daily
difficulties of a selected group of HIV-vulnerable people in Bangladesh,
the challenges posed by these difficulties to HIV prevention work, and
ultimately how one NGO implemented peer education as a participatory
approach to HIV prevention. The perspectives employed are inspired by
postcolonial theory and Freire’s theory of participatory education. The
research takes place in a predominantly Muslim cultural context where
pronounced social stigma is attached to behaviours that increase the risk
of HIV/AIDS. Although cultural approaches have been recognised as
essential to sustainability in HIV prevention, NGOs relate to external
guidelines and often fail to navigate effectively within discursive contexts.
The importance of this research is that it describes how a peer education
programme contributed to increasing participants’ responses to their
own health situation and that of their peers within marginalized
communities. On the basis of my analysis, I suggest some principles for
peer education to further promote the philosophy of Freire.
SAMMENDRAG Artikkelen diskuterer forskning hvor jeg undersøker de
daglige vanskelighetene til en utvalgt gruppe HIV-utsatte mennesker i
Bangladesh, relaterte utfordringer i HIV-forebyggende arbeid, og til slutt
hvordan en lokal NGO implementerte peer utdanning som en deltakende
tilnærming til HIV-forebygging. Artikkelens perspektiver er inspirert av
postkolonial teori og Freires utdanningsteori. Forskningen finner sted i
en muslimsk kulturell kontekst hvor uttalt sosialt stigma er knyttet til
atferd som øker risikoen for HIV/AIDS. Selv om kulturelle tilnærminger
har blitt anerkjent som avgjørende for bærekraftighet i HIV-forebygging
er frivillige organisasjoner ofte knyttet til eksterne retningslinjer og evner
ofte ikke å navigere funksjonelt i diskursive kontekster. Betydningen av
denne forskningen er at den beskriver hvordan et peer
utdanningsprogram bidro til å øke deltakernes respons i forhold til egen
og andres helsesituasjon, innenfor marginaliserte miljøer. Med
utgangspunkt i analysen foreslår jeg noen prinsipp for peer utdanning,
slik at denne ytterligere kan fremme filosofien til Freire.
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KEYWORDS Education to counter HIV/AIDS, postcolonial context,
Bangladesh NGO, participatory education, peer education
Introduction
The issue that I study in this paper is a
programme of participatory education for HIV
prevention in a specific context in Bangladesh. HIV
education for high-risk groups in Bangladesh
represents an important educational initiative in a
situation where people are subjected to stigma and
seclusion. To illustrate this, I examine the situation of
the difficult daily lives of a group of HIV-vulnerable
people which, to some extent, illustrates the
connection of poverty and HIV/AIDS globally. The
respondents have feelings of shame and
powerlessness, leading to a discussion of Spivak’s
(1988) question ‘Can the subaltern speak?’ These
problems stem from the neo-colonial situations of
poverty and marginalization that are still evident in
Bangladesh. It is in this context that I examine the
functions and possibilities of a peer education
programme implemented by a specific NGO.
I have used a postcolonial focus in my analysis, as
postcolonial theory is concerned with the adopting of
an activist position, seeking social transformation
(Young, 2001; Andreotti, 2011; Tuhiwai Smith, 2012).
The importance attached to the use of postcolonial
theory is to see how the processes of domination work
through dialogue and practices, and the role that
dialogue, discourse and critique have in uncovering
and challenging domination (as inspired by the works
of, among others, Fanon, 1952; Said, 1978; and
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Bhabha, 2004). Postcolonial theory emphasizes how
neo-colonial models of education are submerged in
structures of Eurocentric epistemic domination, and
assists in acknowledging the importance of
community-based educational programmes focusing
on interactive participation by learners and educators.
It helped me in interpreting how a specific educational
programme was functioning within its social context.
Similarly, Paulo Freire’s theory of participatory
education (1970) has been of great assistance, and will
be elaborated later.
Discourse analysis is undertaken as an
overarching methodological approach which has
assisted me in grasping discursive meaning through
its realization in practices (Jørgensen and Phillips,
1999; Laffey and Weldes, 2004; Rogers et al, 2005).
Through the methodology and the theoretical
framework I was able to gain significant insights into
aspects of what is essential to HIV education within
marginalized communities in Bangladesh.
The complex forces that shape and influence
human behaviour injurious to health are often poorly
understood. In recent years, increasing attention has
been paid to the manner in which social and cultural
variables influence risk behaviour related to HIV
transmission (Hasnain, 2005; Baxen and Breidlid,
2009; Cornish and Campbell, 2009). In order to
succeed with HIV prevention, it is important to study
the social dynamics and practices of the populations
at risk. Analysis of the cultural context in which risk
behaviour occurs provides meaningful insight into the
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factors that shape and define the external reality
within which this behaviour takes place.
Knowledge of why people behave in certain ways,
as well as the resources available, is vital to be able to
assist in accessing and utilising available preventive
and therapeutic resources (Hasnain, 2005; Chowdhury
and Chandra, 2006; Baxen, 2009). Freire’s problemposing approach (1970) to understanding the social
conditions and factors that lead to risk has great
potential in HIV prevention. If educators start by
asking how HIV-vulnerable individuals see the
problems, causes and solutions, and if this knowledge
is recognized as basic and essential it is possible to be
partners in supporting responses to addressing
treatments and prevention.
Countries created in the context of colonialism
carry within them the aftermath of colonial cultural
norms (Hickling-Hudson, 2011). In the process of the
partition of India after British rule, the decision of
Pakistan and later Bangladesh to become culturally
Muslim states has involved some tension and conflict
regarding cultural norms (Ruud et al, 2011).
Problematic issues with relevance to HIV/AIDS that I
encountered in this study were connected with (a) the
patron-client social orientation of society (cf. Ruud et
al, 2011) where family networks and economic position
play a major role in securing access to healthcare; (b)
social construction of gender as static and determined
by biology; (c) social construction of sexuality where
heterosexuality is the ‘normal’ sexuality, and other
sexualities are made deviant; (d) gender inequity; (e)
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the denunciation of intoxicant use. Most of these
challenges are common in decolonizing contexts.
As a Norwegian student, my socialization into
Eurocentric epistemology was challenged by my
experience of the research project that I describe in
this paper. After I went to Bangladesh to work for a
year through a youth exchange programme, I applied
for admittance to a Masters in International Education
and Development at Oslo University College. My
colleagues were quota students from Sudan, Zambia
and South Africa, and our discussions about global
challenges of aid and education greatly influenced my
thinking.
Going back to Bangladesh for field work, knowing
the basics of the Bangla language, it became clearer to
me how the world’s unequal distribution of power and
resources to a large extent is a result of colonialism
and its aftermath with the current market-led
globalization (cf. Bales, 1999). Wealthy countries and
the powerful international agencies representing their
interests bear a great deal of responsibility for the
continuing underdevelopment of many of the new
nations. The aid provided to the global South for
reducing poverty is not only minimal (Klees, 2010) but
it also, arguably, does not assist with the
‘development’ promised (Hickling-Hudson, 2011).
HIV/AIDS and the Bangladeshi context
through a postcolonial lens
Although there are some studies on issues related
to HIV/AIDS in Bangladesh, there is a gap in the
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literature concerning a cultural, postcolonial
exploration of HIV education aimed at high-risk groups
in this Islamic society. The transferability (Bryman,
2004) of studies on HIV education in other contexts is
often limited. In Bangladesh, the official HIV/AIDS
prevalence rate has remained less than 0.1% (UNAIDS,
2012). HIV is not considered to be a threat to the
general population, but is associated with strongly
stigmatized behaviour like intravenous drug use, maleto-male sex, and extramarital sex (Hasnain, 2005;
Khosla, 2009). Drug use and homosexual practice is
illegal by law, and sex workers are not legally protected
(Ara, 2005; Knight, 2006; Imaan and Alam, 2008).
Stigma and legal restrictions pose huge challenges to
HIV prevention work as they prevent high-risk groups
like men who have sex with men, sex workers, and
injecting drug users from coming forward for
appropriate counselling, HIV testing, and treatment, as
this involves the disclosure of tabooed practices
(Hasnain, 2005; Buncombe, 2008; Khosla, 2009). The
HIV/AIDS prevalence rate has remained low, partly
because of numerous international interventions and,
paradoxically, because of cultural norms. However, if
the contagion was to spread, the country’s
vulnerability is regarded as high (WHO, 2008; USAID,
2008).
Social differences, poverty and HIV/AIDS
Historically, Bangladesh came into existence with
the partition of India and Pakistan, when it separated
from Pakistan in 1971. After the war of liberation,
international charitable aid to Bangladesh was of a
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scale that placed the country among the world’s ten
largest aid recipients through the 1970s and 80s.
Although this was meant to be a support to the
country’s own development efforts, the aid in this
period constituted all of the funding of the country’s
development programmes and in some periods even
more. Influence on public agencies which channelled
the aid became the primary means to economic
prosperity and to political power. The practice of
favouring selected individuals, like relatives and
supporters, was based on deep cultural norms of
reciprocity in interpersonal relations. When an
influential person granted a certain “assistance” to
loyal companions or members of their extended family,
this was recognized as decent behaviour. The military
regimes at the time allowed the beneficiary policy to be
developed as a political tool by using easily available
state funds. Donors and the government allowed
charity aid to fund and maintain an increasingly
affluent middle class which was not made liable for
tax. Instead, the relations between the government and
its citizens began to be about the distribution of cheap
money from aid, so that political leaders and the
middle class were removed from obligations to the rest
of society. A report in 1984 showed that the rural poor
were becoming poorer despite charitable aid (Ruud et
al, 2011).
Many factors contribute to creating social
differences in a given society. In India and the parts
that are now Bangladesh, colonial reinforcements of
traditional caste divisions could also be noted
(Loomba, 2005; Ashcroft et al, 2007). Poverty is often a
problem following a colonial past, and this was indeed
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the case in a Bangladesh struggling with debt after the
war of liberation, having gone through several periods
of governance trouble (Ruud et al, 2011). Impoverished
countries are particularly vulnerable to HIV/AIDS
because they often do not have the resources to buy
the adequate medication and to treat and help patients
with HIV/AIDS. Health care systems are often
overburdened, or not well developed.
Resources for educating the public about
prevention strategies and the consequences of stigma
are equally limited (World Bank, 2013). HIV/AIDS
high-risk groups like sex workers or drug users are
often poverty-stricken or have fallen out of good
society (from the goodwill of families, or from work
markets), and face a multi-faceted challenge in a
society where their disempowered situation hinders
access to health services and suppresses their agency
to protest.
Sexuality and HIV/AIDS
European Renaissance travel writings and plays
repeatedly connected deviant sexuality with racial and
cultural outsiders and far away places. Non-European
peoples were imagined as more easily given to samesex relationships, and various accounts served to
define deviant and normative behaviour in Europe.
Colonialism thus entrenched the connections between
foreign lands and deviant sexualities (Loomba, 2005).
The Church in pre-industrial Europe, and the
scientific study of ‘sexuality’ that grew in the 1800’s,
speaking of ‘nature’ and biology (Segal, 1997; Scott
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and Marshall, 2009) were also influential to Western
sexuality discourse. The continued condemnation of
homosexual practice in Bangladesh, strengthened by
Muslim norms, has implications in relation to
HIV/AIDS in that some men who have sex with men
hide core aspects of their identity, not daring to seek
health information and services.
Gender inequity and HIV/AIDS
In some Muslim societies, social norms
systematically accord a lower status to women
compared to men. In Bangladesh, this is apparent in
heterosexual relations as well as in the economic and
social spheres of life. This discrimination has adverse
implications for the access of women to education,
nutrition, health information, and services within and
outside the household (Hasnain, 2005; Khosla, 2009).
In relation to HIV/AIDS, gender inequity increases
poverty and the silence surrounding risk behaviour.
For many women there might be social barriers
against demanding safer sexual behaviour from their
husbands and partners (Rahman, 2005), which
arguably has implications for the spread of HIV/AIDS.
Legal frameworks
The legal frameworks affect HIV high-risk
communities in Bangladesh. The Narcotics Control Act
of 1990 makes possession of tools used for taking
drugs punishable with a minimum imprisonment of
six months (Knight, 2006; Imaan and Alam, 2008). In
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the year 2000, an amendment to these drug-use laws
offered government support for NGOs working with
detoxification and support for drug users that actively
seek to end their addiction, under the existing health
system.
Needle-exchange programmes rely on strong
advocacy by law-enforcement authorities (Knight,
2006). The relevance of this to the HIV/AIDS situation
is essential, as the sharing of needles represents a
major factor in the spread of the disease. Furthermore,
for countries grappling with decolonization, a major
problem is contestation over inherited laws. For
instance, legal barriers for men who have sex with men
in Bangladesh include Section 377 of the Penal Code
(1860) that criminalizes homosexual practice
(CommonLII, 1860). This prevents people from seeking
prevention material and health care.
A participatory approach to HIV prevention
through a Freirean lens
Postcolonial theory critiques dominating approaches to
education (Hickling-Hudson, 2011; Breidlid, 2013),
and the challenge is to implement participatory
models of education in the Bangladeshi, Islamic
context. A Freirean approach to education is of
significant value in this.
Paulo Freire worked in Brazil and created literacy
education programs that promoted dialogue and power
sharing between participants. Social critique and
transformation were the goals of these education
programmes. Components of this approach included
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problem posing contrasted with problem solving,
analysis of the root cause of conditions, and exchange
between participants and educators. How knowledge is
used and created, who creates it, and for what purpose
were all stressed in Freire’s popular education
approach. Freire contrasted popular education with
the model he called “banking” education, where a
knowledgeable expert would ‘deposit’ knowledge into
the minds of learners, much like a person making a
deposit of cash into a bank account.
The banking model was seen as static, unidirectional,
and reinforced the power of the expert, both as a
source of knowledge and in the expert’s role of
replicating this knowledge (Freire, 1970; Mayo, 1999;
Zanoni, 2013). “One cannot expect positive results
from an educational or political action program that
fails to respect the particular view of the world held by
the people. Such a program constitutes cultural
invasion, good intentions notwithstanding,” he
stressed (Freire 1970, p 84).
Peer education is an educational model that is inspired
by Freire’s approach. It is a process of carrying out
informal or organized educational activities with
individuals and small groups of peers, over a period of
time. Peer education is based on the reality that many
people make changes not only based on what they
know, but on the opinions and actions of their close,
trusted peers. The main role of peer educators is to
help the participants define their concerns and seek
solutions through the mutual sharing of information
and experiences.
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Peer educators are the best persons to disseminate
new information to the peer participants and can
become role models by ‘practicing what they preach’.
Since the educators are from the same group, they can
empathize and understand the emotions, thoughts,
feelings and language of the participants and,
therefore, relate better to them (Chowdhury and
Chandra, 2006; Alcock et al, 2009; UNODC, 2013).
Peer education can take place on a street corner, at a
social club, in a train station or any other place where
people feel comfortable.
Methodology
Research is never neutral, and our
representations of other people are intimately linked to
our own socioeconomic, gendered, cultural, and
historical positioning calling for a heightened selfreflexivity. Even in trying to describe and interpret
culture from an insider’s perspective, knowledge will
always be subjective and relative. I cannot know what
it is to be a Bangladeshi participant in this local
setting. I am aware that there is a possibility that I
might bring those I am studying to silence through the
way I write. My chosen methodologies are in
themselves products of Western epistemology.
I used a discourse studies approach throughout
my research (Jørgensen and Phillips, 1999; Laffey and
Weldes, 2004; Rogers et al, 2005). The study was
qualitative and designed as a case study using
elements from ethnography. These are reflective
methodologies (Bryman, 2004) that could lead to a
greater depth in my understanding of the research
findings. I collected data during three months of
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participant observation at three health centres and at
the main office of an NGO working with HIV/AIDS
prevention in a city in the north-west of Bangladesh.
In addition, data from four focus group discussions
with participants at the NGO, and from 10 semistructured interviews with peer educators, centre and
project managers constitute the material for analysis.
Interviews and focus group discussions were partly
conducted, taped and transcribed with the assistance
of a local interpreter, a female Master’s student of
social sciences who was a contemporary and
acquaintance of mine. I trusted her accurate and
distanced approach to the work. Data was also
gathered through document analysis.
The fieldwork was conducted during August,
September and October 2008. The project was based
on the standards and ethical guidelines and terms of
Oslo University College. Informed consent was
obtained from the NGO. All potential participants were
informed about the content and scope of the research,
and the confidentiality and anonymity.
The validity of my analysis is premised on the
communicative dialogue I had with my respondents
and interpreter during field work, the oral quotations
from them that I attached to my analysis, email
correspondence with staff during analysis, and on my
own epistemic background. The use of more than one
method has hopefully helped to reduce biases which
might have occurred if relying exclusively on one data
collection method, source, analyst, or theory (Bryman,
2004).
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Within a critical discourse analysis tradition,
discourse has been defined as language use as social
practice. According to Rogers et al (2005) "Critical
Discourse Analysis focuses on how language as a
cultural tool mediates relationships of power and
privilege in social interactions, institutions, and bodies
of knowledge" (p 367). I paid attention to the ways in
which language was communicated and how
discursive meaning was created and recreated through
practices. The methodology helped to sense the
everyday logic, customs, and reasoning of programme
participants, peer educators and NGO staff.
In the next sections, I set out the main findings of
the research.
The NGO
The Non-Governmental Organization in focus had
existed since the late 1980s, and was founded by a
group of local adults to work for the victims of a flood.
The NGO called itself a non-profit development
organization that aimed to ensure access to basic
human rights and social security for the most socially
disadvantaged groups of society. HIV/AIDS prevention
was one of its prioritized areas of work.
As with most initiatives to prevent the spread of
HIV/AIDS in Bangladesh, the NGO worked with biand multilateral aid partners to target high-risk
communities. The NGO operated three drop-in health
centres in the city; one for men who have sex with
men, one for female sex workers, and one for drug
users. Peer educators conducting outreach work
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guided people from the different groups to come to the
health centres. At these centres, participants could get
free health check-ups and further HIV/STI education.
They were welcomed to individual counselling, HIV
testing, and given free syringes and/or condoms.
Participants could drop in to rest, to sleep, or to chat.
The NGO sent project proposals to funding aid
agencies. Staff at the NGO emphasized that peer
education had long proved functional, and they
maintained the validity of this approach. They stressed
that the content was negotiated in cooperation
between the parties. The NGO was dependent upon
external funding. Some aid came with strict
conditions, whilst some opened for a more individual
approach. Staff explained that some funding lasted for
three years; some for longer.
What the NGO considered to be HIV prevention
could be seen by critics as the promotion of an
irreligious lifestyle (cf. Buncombe, 2008). The NGO
tried to remain in continuous dialogue with religious
leaders. “Some Imams approve of utilising Friday
sermons to reach out to the greater society with an
HIV message. Many do not approve. It is anyway in the
interest of our projects to stay in continuous dialogue,”
one of the centre managers stressed. Religious leaders
are part of many personal interactions and
conversations. Religious discourses of respect for life,
and not harming others, could be referenced to
encourage social action on health. “Imams have a
great opportunity to do a lot in our society. Everyone
respects the Imams,” he continued. However, the
common attitude that ‘irreligious’ practices should not
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exist and therefore should not be the subject of focus,
represented a challenge for the NGO. The staff
continuously needed to justify their efforts. They
explained to neighbours of the health centres and to
community stakeholders that HIV/AIDS is a real
problem of significance in society, and that stigma
provokes its spread.
Both ignorance and an overarching social stigma
towards high-risk populations made it difficult for the
NGO to gain social and material acceptance for its
work in the local community, to involve religious
leaders and other community stakeholders effectively,
to reach the high-risk communities, and to be trusted
and understood by these. The NGO worked cautiously
and emphasized the importance of a cultural approach
in its efforts.
In a cultural approach to HIV prevention, insight
into daily life is essential. In the following section, I will
examine some of the daily life challenges of
participants in the NGO’s peer education programme.
Daily difficulties of individuals from HIV highrisk groups
While sexuality and gender is linked with core
social identity creation (Foucault, 1976; Butler, 1997),
sex work and drug use may be discussed as poverty
problems. There are various reasons why people
engage in behaviour that put them at particular health
risk: for pleasure, love, to earn money, or because they
are forced to do so.
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Men who have sex with men (MSM)
The men at the NGO Health Centre for men who
have sex with men fell in love with people of the same
sex, or/and identified as transgenders (hijras), or/and
as male sex workers. The term ‘homosexual/-ity’ was
not commonly used. One participant expressed
conflicting feelings about love and sexual practice. “I
have asked myself and God many times; ‘why are we
MSM?’ […] Biologically I am a man but I fall in love
with people of the same sex. It is very difficult to be so
different from other people.” The young man was
trying to find answers to his perception of being
different from others, from a publicly ‘normal’ model of
being. It bothered him to an extent that he had
repeatedly asked God to alter him in this wish. Several
respondents expressed the difficulties of getting work.
A respondent who identified as transgender
stressed that “the general population does not wish to
work with us. They do not know our feelings, and they
do not want to know either. People may not tolerate
the fact that we behave in feminine ways.” It seemed
as though behaving in ‘feminine ways’ was not socially
tolerated, resulting in a degree of exclusion from job
markets, and consequently from social communities.
Expectations of masculinity were strong. “It is even
difficult for us to move through the streets,” another
respondent stressed. “Many people hate us because we
are different. They cannot tolerate us.” This person’s
hesitation to move around freely was caused by
previous traumatic experiences of harassment in his
neighbourhood. Overall, they expressed deeply
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internalised feelings of shame, related to both love and
illicit sexual practice.
Colonial constructions of sexuality and gender,
with the condemnation of same-sex relationships had
an impact on the lives of these men. Islamic-normative
expectations that sex is for the purpose of conceiving
children within heterosexual marriage, underpinned
this. The interviewed participants emphasized the
burden of the strong stigma upon people who deviated
from the discursive expectations. This stigma
prevented individuals from moving peacefully through
the streets and from getting work. Physical experiences
made them attempt to hide their status as MSM at
home and in public, not daring to seek information, try
to get condoms, or test for HIV. The confidentiality of
the NGO health centre seemed to be an appreciated,
supportive sanctuary.
Female sex workers
Combinations of various circumstances including
poverty, misfortune, limited options for women in
working life, and family ejection, are reasons why
women may find that sex work is the only option. The
conditions for women in sex work in Bangladesh are
extremely harsh. Sex work in venues other than
registered brothels is illegal (Chan and Khan, 2007).
No legislation has been passed since independence
(1971) that recognises commercial sex work as a legal
way of earning income, which means that sex workers
have no right to any formal licence (Ara, 2005). This
ambiguity makes harassment of sex workers easier
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and their access to healthcare services more difficult.
It also prevents the creation of, and access to, work
safety mechanisms (Khosla, 2009). To illustrate this
lack, one programme participant stressed: “We earn
money to the client’s choice. We cannot say anything.
We want to say a fixed price but we may be tortured if
we do so, and no-one is there to help.”
The participants at this second Health Centre
expressed a need for housing. “Our main worry is that
we need a personal house. On Fridays, when [the
NGO] is closed, we stay the whole day within the
railway station boundaries and the railway people and
door-to-door salesmen know that we are staying there
and they disturb us,” a respondent said. This provides
insight into a situation marked by insecurity. Some
mentioned violence and harassment awaiting those of
them forced to live on the streets. The lack of family
acceptance was equally emphasized. “We have no
families.” “I have a husband. He hit me yesterday.” “I
want to build my family but it is impossible because
my husband doesn’t allow me to come home to the
family. I was tricked into prostitution and my husband
said I am no good girl.” These women had little option
but to be submissive to husbands’ decisions. It was
difficult to escape the sex trade. “All people say:
Change your lives, come back to our society. But when
we try to come back to society, this same society
cannot accept us. So we cannot change.” The sex
workers felt trapped within their situation because of
stigma, and further stigmatised through their practice.
In traditional Islam as in many religions, the value
of sex for the purpose of children and within marriage
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is basic and essential. Sex work is an infringement of
such values. The female victims of this trade were
treated with disrespect, experienced physical and
psychological violence and danger, and faced a
constant struggle to acquire money. They were
excluded from families and social networks, and did
not dare to seek public health services. Some of the
respondents were illiterate and stressed that they had
no accurate knowledge of disease or prevention prior
to their involvement with the NGO.
Individuals addicted to drugs
The third centre under study was the Health
Centre for drug users. Here, there were predominately
male adults who expressed a wish to quit drugs, and
some had overcome bad addictions. Many of them
used or had used syringes as a way of taking drugs. As
a consequence of official laws, “[i]t is not legal to sell
needles and syringes without prescription in
Bangladesh. Illegal shops are there though, selling
needles for a high price,” the manager at the centre
explained. Without the opportunity to buy equipment
easily, the solution for injecting drug users is often to
share syringes, and to use each syringe until it breaks
or gets lost, hence increasing their vulnerability to HIV
along with their spouses and sex partners.
Drug use is a major problem particularly among
rickshaw-pullers and mini-taxi-drivers, and among
male and female students, programme participants
stressed, being mostly unemployed themselves. They
had a hope to improve their lives in general, wishing to
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get work or to develop their own businesses. Their
major worries were expressed as being related to
money, or a lack thereof, and a lack of something
meaningful to do. For some, a lack of social inclusion
or acceptance was also an issue.
Getting tested for HIV at the centre was
encouraged, and free. However, the participants
expressed reluctance about getting tested. This
seemed to stem from a combination of indifference
and, as one stated: “It is difficult for people to explain
the topic of HIV/AIDS in our families.” Discussing
HIV/AIDS meant discussing drug use and sexual
behaviour, something which some participants
attempted to avoid at home. Not daring to discuss
their problems in public for fear of social exclusion
and imprisonment seemed to hinder their
rehabilitation into the community.
Visions for the future
Respondents at the three centres expressed
visions of a better future. The MSM respondents
desired to be accepted by society, to not have to feel
shame when they fell in love or challenged
expectations of masculinity. The drug users desired to
get clean from drugs, to get work or to be able to start
their own businesses. The women working as sex
workers expressed a wish for a personal house or
shelter, a need for safety, for the opportunity to be part
of a family, to see their children, and they clearly
stressed the need for assistance to alter their
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situations: “We want to change our lives. If [this NGO],
some other NGO or a government initiative would give
us the opportunity to earn money in a right way, we
could change our lives. It could be courses on
handicrafts, sewing, or garments labour. This life is
not safe and we cannot escape it on our own.” The
various respondents’ visions for the future were basic
and concrete: shelter, money, work, safety, love and
families.
The questions of agency and the ability to ‘speak’
The respondents were in different ways
disempowered in the social context of a combination of
the aftermath of colonialism and the norms of
traditional religion and patriarchy. However, when
emphasizing the destructive power of colonialism, one
may wonder if it is necessary to position colonized
people as victims, incapable of answering back. On the
other hand, if suggesting that the colonial subjects can
‘speak’ and question authority, one may romanticize
such resistant subjects and underplay colonial
violence. One may ask if the voice of the subaltern can
be represented by the intellectual. In ‘Can the
Subaltern Speak?’ (1988), Gayatri Spivak suggests
that the combined workings of colonialism and
patriarchy in fact make it extremely difficult for the
oppressed colonial subject to speak or be heard.
However, her picture of subaltern ‘silence’ is
problematic if adopted as the definitive statement
about colonial relations.
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How are the questions of agency applicable to the
socially stigmatized and marginalized people in this
local setting? An answer to this is that people are not
trapped in their subjectivity beyond the power of
choice, recognition or resistance. A person exercises
power even by being (Butler, 1997). Individuals make
choices also by keeping quiet, and the discourse is
recreated also by silence. Relevant to this is the
conclusion to Black Skin: White Masks where Frantz
Fanon rhetorically proclaims an almost Cartesian
agency for the colonized subject: “I am my own
foundation. And it is by going beyond the historical,
instrumental hypothesis that I will initiate the cycle of
my freedom” (Fanon, 1952, p. 231).
In the very processes of the emergence of colonial
and neo-colonial discourses, they are diluted and
hybridized. People in these contexts can negotiate the
cracks of dominant discourses in a variety of ways
(Bhabha, 2004; Loomba, 2005). In theory, peer
education provides a framework for problem posing
dialogue that should increase agency, which may
assist people in negotiating disempowering discourses.
In the following section, I will discuss the form of peer
education that was implemented in this particular
setting.
Peer Education in the setting of HIV
prevention work
Peer education in the HIV prevention field has
varying outcomes. Much remains to be learned about
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the factors which lead some projects to succeed while
others fail (Cornish and Campbell, 2009).
The peer education approach assisted the NGO in
getting through with their messages. A female project
manager at the main office stressed: “It is difficult for
us; we cannot easily go to talk with the sex workers in
their own communities. […] I know where they are
living but they are not free or relaxed with me.”
Furthermore, she stressed: “Peer educators are
selected from targeted populations’ own communities.
The peer educators know the lives of the people; they
are working with social networks that are known to
them.”
The peer educators seemed motivated by an
authentic interest in the programme. A female peer
educator who had been addicted to intoxicants in the
past explained how she wished to assist others out of
addiction. Rehabilitation required a long process of
counselling, she stressed. “We have been there
ourselves. We know that we need to be patient. […] At
first the drug users may not talk about their drug
problem with us, they have to take drugs first. But we
wait until they are clean again before talking. And after
talking sometimes, they understand that we want to
help them.” She stressed the need for patience, and
she spoke of her work with enthusiasm.
The peer educators working from the MSM centre
emphasized the message that ‘your body is your life’ to
get participants engaged in discussion. This approach
was part of their training as educators. However, “the
societal condemnation is huge. When we try to discuss
this message with our peers they cannot easily
Postcolonial Directions in Education, 2(2), pp. 226-262, 2013,
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understand it,” one of them stressed. The message can
be interpreted to incorporate a view on sexuality and
on individual choice that may be rather radical in the
traditional setting it was to function. However, in the
discussion that followed participants could share and
discuss their concerns, experiences, and emotional
issues that emerged. To encourage active participation
role playing was used in the group meetings to
improve, for instance, communication with partners
and clients about safer sex practices. Problem posing
was employed to assist participants work together to
solve problems (cf. Freire, 1970).
The educational dialogue employed in the
programme may be seen as to increase the
‘effectiveness’ of HIV prevention, but in this setting it
can also be seen as problem posing in that
participants created a space to raise concerns and
offer critique of disempowering forces. What happened
was frank dialogue about social practices that
provided the context for the use of the content
knowledge. While there were summary points at the
end of the educational sessions about what the ‘take
home’ messages should be, what participants also
gained was viewpoints about themselves and their own
practices in a context that could address and support
their health, family and community (Zimmerman et al,
1997).
The peer education in this particular setting
functioned well in basic ways: high-risk communities
were reached, and the peer educators’ messages were
understood by the community members in the field.
These dared to come to the centres for educational
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follow-up and health check-ups. Furthermore, peer
education proved enabling for the participants to build
social networks which could potentially lead to
improved preventive behaviour and social action to
improve their lives in general.
Many participants came to the centres daily. It
was explained to me that after time and further
training many got engaged in work as peer educators.
However, the work for the peer educators was not
paid. It is a matter of discussion why the poorest
people of society should remain unpaid for their work.
‘Empowerment’ of communities is sometimes used as a
euphemism for the reduction of costly services, as
communities are expected to take on responsibility for
their health, with little or no pay. A further problem is
the inadequacy of consultation. In the peer education
programme neither participants, nor peer educators
were directly included in the programme planning and
curriculum design.
‘Sustainability’ is another euphemism, used to
mean the continuation of a programme after funding
ends. If acknowledging that current behaviour
patterns are a product of a powerful set of social
conditions, to change this whole system will require
enormous investment of time and resources. The
impetus to achieve ‘sustainability’ should not lead to
unrealistic assessments of the speed at which the
development of independence and power among
community members can be achieved (Cornish and
Campbell, 2009). Staff stressed the amount of extra
work, and the very limited outcomes, that short-time
programmes would bring about.
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Concluding remarks
The context of HIV/AIDS in a postcolonial,
Muslim cultural context in Bangladesh represented
particular challenges in HIV prevention work. The
participants at the NGO faced challenges in their daily
lives. The existing social and legal frameworks did not
provide an environment for any safe disclosure of risky
circumstances, and they were reluctant to share their
needs in public and to seek information and health
services. This has implications for the spread of
HIV/AIDS. If the consequences of moving away from
existing patterns of discursive dominance are too
threatening, people may attempt to avoid them,
upholding the dominant discourses, and exacerbating
their own vulnerability to the disease.
Through the discussion of daily life challenges I
attempted to show the importance of emphasizing
context in HIV prevention. A cultural approach was
vital for the NGO to succeed, and the NGO worked
cautiously through peer education and through
involving community stakeholders like Imams. The
NGO’s cultural approach, as contrasted to a more
biomedical approach, was well suited to the challenges
of HIV prevention within these marginalized
communities. This programme showed that it is
possible to partially compensate for very
disempowering social conditions by addressing the
community’s social challenges. However, to strengthen
this focus the participants could have been involved
more directly in programme planning and curriculum
design.
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The programme participants were provided with
health information. In addition, the educational
dialogue offered an opportunity to raise social
concerns. To be able to see oneself in a social context
where discourse is created and recreated, is a step on
the way towards combating shame, which is a major
hindrance for agency. In the process of
conscientization, the ‘banking education’ from an
authority or formal expert may prove
counterproductive. This study showed how
participants and educators developed a form of
ownership of the programme, working together to solve
problems and making decisions about issues of
concern to them.
On the basis of my analysis of this particular
setting, I suggest the following principles for peer
education that would deepen its resonance with the
philosophy of Freire:
Address the social, cultural challenges
disempowering the communities.
Core problems and disadvantages such as poverty
and stigma limit the impact of any efforts to change
health-related behaviour.
Involve religious leaders and community
stakeholders.
Community intervention is a complex social
process which depends for success upon the action
and support of various community members. Any
Postcolonial Directions in Education, 2(2), pp. 226-262, 2013,
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effort directed at HIV prevention must take into
consideration the powerful impact of religious leaders
in the community as they play a critical role in Muslim
culture. For HIV prevention programmes to be
successful, continuous dialogue with religious leaders
and community stakeholders is a key element.
Anticipate a lengthy time frame.
Social change is a slow and gradual process, and
quick fixes are unlikely to work. Project planning
needs to allow for an extended period of time and very
gradual improvements.
Involve the participants directly in the programme
planning and curriculum design.
The active involvement of the key participants in
programme planning, curriculum design, and
implementation is more likely to produce a programme
sensitive to the local context, and with local
commitment. The participants in this setting were
clear in their visions for the future, expressing
concrete needs that could help them to live more
functional daily lives. Their experiences represent
extremely important knowledge about what is helpful
for these groups.
Support active participant groups.
Decolonization cannot be limited to
deconstructing the dominant story and revealing local
Postcolonial Directions in Education, 2(2), pp. 226-262, 2013,
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voices, or local histories. This and much more is
needed to assist people improve their current
conditions and reduce their vulnerability to getting
HIV/AIDS. Peer education is a tool for decolonization;
it is about constructing one’s own responses in
cooperation. However, historically disempowered
communities are not immediately in a position to run
and lead a challenging programme or activist group.
Without intensive support the impact of such
initiatives is limited.
This paper has sought to understand a
programme of participatory education for HIV
prevention in a specific context in Bangladesh. The
programme reached out with factual knowledge of
disease and prevention to marginalized communities.
In addition, the peer education worked as a force of
critique with the participants. These discussed social
practices and responded to their disempowering
situations through active participation as educators
and peers. However, the cultural, participatory
approach can be promoted even further in peer
education. It is a promising educational approach to
challenge neo-colonial discourses.
Postcolonial Directions in Education, 2(2), pp. 226-262, 2013,
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255
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